A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect?
Diplopia.
Masklike expression.
Twitching of the face.
Agitation.
The Correct Answer is A
Answer: A. Diplopia.
Rationale:
A) Diplopia: Diplopia, or double vision, is a common symptom in multiple sclerosis (MS) due to demyelination of nerves in the brainstem, affecting eye movement coordination. This visual disturbance is frequently seen in MS clients and may worsen during flare-ups.
B) Masklike expression: A masklike expression is more commonly associated with Parkinson’s disease rather than multiple sclerosis. This characteristic facial appearance is due to muscle rigidity, which is not typically a manifestation of MS.
C) Twitching of the face: Facial twitching, or fasciculations, is not typically a primary symptom of multiple sclerosis. While muscle weakness and spasticity are common in MS, twitching is more commonly seen in conditions such as amyotrophic lateral sclerosis (ALS).
D) Agitation: Agitation is not a primary symptom of MS. While MS can lead to cognitive changes or mood disturbances, such as depression, severe agitation is more commonly linked with other neurological or psychiatric conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
Correct Answer is B
Explanation
Choice A rationale:
(Fluticasone) Fluticasone is a corticosteroid inhaler used for the long-term management of asthma symptoms and prevention of asthma attacks. It is not suitable for treating acute asthma
attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice B rationale:
(Albuterol) Albuterol is a short-acting beta-agonist bronchodilator and the preferred medication for relieving acute asthma symptoms and treating asthma attacks. It works by quickly relaxing the airway muscles, making it easier to breathe during an asthma attack. Therefore, this is the correct choice for medications to treat an acute asthma attack.
Choice C rationale:
(Salmeterol) Salmeterol is a long-acting beta-agonist bronchodilator used for the prevention of asthma symptoms but should not be used for treating acute asthma attacks. It has a slower onset of action compared to short-acting beta-agonists like albuterol. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
Choice D rationale:
(Beclomethasone) Beclomethasone is a corticosteroid inhaler used for long-term asthma management and prevention of asthma symptoms but is not appropriate for treating acute asthma attacks. Therefore, this is not the correct choice for medications to treat an acute asthma attack.
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